Specifications Manual for Joint Commission National Quality Measures (v2018A)
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Release Notes:
Data Element
Version 2018A

Data Element Name: Nimodipine Administration Time
Collected For: CSTK-06
Definition:The time (military time) for which the first dose of nimodipine was administered to a patient with subarachnoid hemorrhage at this hospital. Nimodipine inhibits calcium transport into vascular smooth muscle cells, thereby preventing or limiting cerebral vasospasm.
Suggested Data Collection Question:What is the time of nimodipine administration for this patient at this hospital?
Format:
Length:5 - HH-MM (with or without colon) or UTD
Type:Time
Occurs:1
Allowable Values:


HH = Hour (00-23)
MM = Minutes (00-59)
UTD = Unable to Determine

Time must be recorded in military time format. With the exception of Midnight and Noon:
  • If the time is in the a.m., conversion is not required
  • If the time is in the p.m., add 12 to the clock time hour

Examples:

Midnight = 00:00
Noon = 12:00
5:31 am = 05:31
5:31 pm = 17:31
11:59 am = 11:59
11:59 pm = 23:59

Note:
00:00 = midnight. If the time is documented as 00:00 11-24-20xx, review supporting documentation to determine if the Nimodipine Administration Date should remain 11-24-20xx or if it should be converted to 11-25-20xx.

When converting Midnight or 24:00 to 00:00, do not forget to change the Nimodipine Administration Date.
Example:
Midnight or 24:00 on 11-24-20xx = 00:00 on 11-25-20xx
Notes for Abstraction:
  • Use the time at which initiation of nimodipine administration was first documented. If a discrepancy exists in time documentation from different sources, choose the earliest time. If there are two or more different nimodipine administration times (either different nimodipine episodes or corresponding with the same episode), enter the earliest time.
  • For times that include “seconds”, remove the seconds and record the time as is. Example: 15:00:35 would be recorded as 15:00
  • Nimodipine administration time refers to the time that the first dose of nimodipine was administered.
  • Do not use physician orders as they do not demonstrate administration of nimodipine treatment (in the ED this may be used if signed/initialed by a nurse).
  • If the time of nimodipine administration is unable to be determined from medical record documentation, select “UTD”.
  • The medical record must be abstracted as documented (taken at “face value”). When the time documented is obviously in error (not a valid time) and no other documentation is found that provides this information, the abstractor should select “UTD”.
    Example:
    Documentation indicates the nimodipine administration time was 3300. No other documentation in the medical record provides a valid time. Since the nimodipine administration time is outside of the range listed in the Allowable Values for “Hour,” it is not a valid time and the abstractor should select “UTD”.
    Note: Transmission of a case with an invalid time as described above will be rejected from the Joint Commission's Data Warehouse. Use of “UTD” for Nimodipine Administration Time allows the case to be accepted into the warehouse.
Suggested Data Sources:

  • Emergency department record
  • Nursing flow sheet
  • Progress notes
  • Medication administration record (MAR)
  • Medical transport records
  • Medication reconciliation form
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Nimodipine Administration Time
Specifications Manual for Joint Commission National Quality Measures (v2018A)
Discharges 07-01-18 (3Q18) through 12-31-18 (4Q18)
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